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    Organization Registration Form

    Tell Us About Your Practice

    Organization Name*

    Office Contact*

    Phone*

    After-hours phone number (for critical issues and alerts)

    Fax*

    Email*

    Address*

    Address Line 2

    State*

    ZIP / Postal Code*

    Ordering Providers & Authorization

    Provider Information*

    Consent*

    I hereby authorize Genics Laboratories and its partners to test, results, and bill all the requisitioned patients